Pneumothorax
Key points
Pneumothorax predisposition
Tall thin body habitus
Marfans/Ehlers-Danlos
Cystic fibrosis
Asthma
Investigations
CT - 36% sensitivity for bullae
Complications
Pulmonary oedema after re-expansion
Air embolism - due to positive pressure ventilation and BP-venous fistula - put in chest drain - thoracotomy if not successful
British thoracic society guideline 2022 summary
For primary spontaneous pneumothorax - conservative management in well patients is associated with less recurrence and shorter hospital stays
No significant differences between bullectomy and surgical pleurodesis for ongoing air leak in terms of hospital stay, pneumothorax recurrence, need for further treatment, complications, air leak duration, and mortality, but evidence on pain, breathlessness, and quality of life is insufficient
Complications and length of stay are less with VATS compared to thoracotomy, but recurrence rates are slightly higher
Standard scenario
Ensure resuscitated and stable
Needle decompression (now done in mid-axilliary line - US ATLS guidelines) if tension - do not image first
History:
Trauma
Previous episodes
Medical history of asthma, CF, Marfans
Examination:
Marfanoid features
Tall stature
Management:
Aspirate or chest drain - give 24 hours
If successful, home
If not, CT scan for bullae (only 36% sensitive) and bronchopleural fistula
Then VATS + apical bullectomy + pleurectomy
Joharifard (JPS 2017) Pleurectomy vs pleural abrasion - 9 vs 40% recurrence rate
40-60% recurrence if just aspirated
5-10% recurrence after VATS
BTS guidelines:
No air travel for 7 days after resolution
- If spontaneous - No deep sea diving unless bilateral pleurectomy
- If traumatic - no contraindication if normal lung function on spirometry
References
Joharifard S, Coakley BA, Butterworth SA. Pleurectomy versus pleural abrasion for primary spontaneous pneumothorax in children. J Pediatr Surg. 2017 May;52(5):680-683. doi: 10.1016/j.jpedsurg.2017.01.012. Epub 2017 Jan 27. PMID: 28168984.
Roberts ME, Rahman NM, Maskell NA On behalf of the BTS Pleural Guideline Development Group, et al
British Thoracic Society Guideline for pleural disease
Thorax 2023;78:s1-s42.